Annals for Hospitalists - June 2023
Authors: David H. Wesorick
Journal: Annals of Internal Medicine (2023)

Web ExclusivesJune 2023Annals for Hospitalists - June 2023FREEDavid H. Wesorick, MDDavid H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202306200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesKey Clinical Concepts for Diagnosis and Treatment of Alcohol-Associated Hepatitis for Hospitalists—Elisa Pose, MD, PhD, and Ramón Bataller, MD, PhDIn this article, the authors explain how to recognize, determine the severity of, and treat alcohol-associated hepatitis.Highlights of Recent Articles From Annals of Internal MedicineEffects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals: A Stepped-Wedge, Cluster Randomized TrialAnn Intern Med. 2023;176:743-750. Published 6 June 2023. doi:10.7326/M22-3679This cluster randomized controlled trial (RCT) evaluated the implementation of an assisted walking program for patients aged 60 years or older who were admitted for more than 2 days at 8 Veterans Affairs hospitals. The supervised walking program involved an initial gait and balance evaluation followed by daily supervised walks. Hospitals received guidance on creating the programs, but they utilized and trained their own personnel without additional funding. Patients admitted after implementation of the program (n = 9070) had lower odds of being discharged to a skilled-nursing facility compared with preimplementation data (odds ratio, 0.6 [95% CI, 0.5 to 0.8]), without a significant difference in length of stay or inpatient falls.Key points for hospitalists include:This study shows that Veterans Affairs patients hospitalized after the implementation of a supervised walking program were less likely to be discharged to a skilled-nursing facility than control participants (absolute difference, 8% vs. 13%). If extrapolated to the total number of discharges from Veterans Affairs hospitals in 2019 (600 076), this would have led to 30 004 fewer discharges to skilled-nursing facilities.This study may have been limited by low rates of participation—only 6.3% (n = 574) of eligible postimplementation hospitalizations included documentation of more than 1 supervised walk. It is unknown whether this was due to lack of documentation or other unmeasured factors.The level of physical activity (that is, physical therapy, patient-initiated walking, and so forth) in the control group (preimplementation) is not well described.Risk for Bleeding-Related Hospitalizations During Use of Amiodarone With Apixaban or Rivaroxaban in Patients With Atrial Fibrillation: A Retrospective Cohort StudyAnn Intern Med. 2023;176:769-778. Published 23 May 2023. doi:10.7326/M22-3238This retrospective cohort study evaluated whether amiodarone, when compared with other antiarrhythmic medications (flecainide and sotalol), inferred a higher risk for bleeding when taken along with a direct factor Xa inhibitor (apixaban or rivaroxaban). Using Medicare claims data from 91 590 patients with atrial fibrillation, the authors found that amiodarone plus a direct factor Xa inhibitor was associated with a 44% increased risk for bleeding-related hospitalization (hazard ratio, 1.44 [95% CI, 1.27 to 1.63]). They also found that this combination was associated with an increased risk for total mortality (hazard ratio, 1.28 [CI, 1.15 to 1.44]).Key points for hospitalists include:Amiodarone inhibits both hepatic cytochrome P450-3A4 and multidrug transporter P-glycoprotein, which are important in metabolism and absorption and excretion of direct factor Xa inhibitors, and has previously been shown to increase plasma concentrations of these drugs. This study suggests that this effect has measurable clinical consequences.Apixaban plus amiodarone was only associated with an increased risk for bleeding-related hospitalizations when the HAS-BLED score was greater than 2, whereas rivaroxaban plus amiodarone was associated with increased risk regardless of HAS-BLED scores.Major Update: Masks for Prevention of SARS-CoV-2 in Health Care and Community Settings—Final Update of a Living, Rapid ReviewAnn Intern Med. 2023;176:827-835. Published 16 May 2023. doi:10.7326/M23-0570This updated review of 3 RCTs and 21 observational studies showed that, in community settings, masking may be associated with a small reduction in SARS-CoV-2 infection risk, but that data for masking in health care settings is limited. The authors also found a single RCT that showed noninferiority for surgical masks compared with N95 respirators in preventing SARS-CoV-2 infections.Key points for hospitalists include:This updated review found low to moderate strength evidence that mask use decreased SARS-CoV-2 infection in the community setting (no change from the prior review).A single, newly included RCT showed that surgical masks were noninferior to N95 respirators in preventing SARS-CoV-2 infection; however, noninferiority was defined as anything less than doubling of risk. A benefit for N95 respirators cannot be ruled out based on the available evidence.Ultimately, the evidence for masks in preventing SARS-CoV-2 remains poor due to a lack of high-quality studies, as most have significant methodological shortcomings. Mask use recommendations, therefore, continue to be made at the institutional level on the basis of local infection rates, expert opinion, and societal influence. Editorialists discuss both the difficulties and the importance of research in this area to define the role of masking for the inevitable next viral epidemic.How Would You Manage This Patient With Recurrent Diverticulitis? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAnn Intern Med. 2023;176:836-843. Published 13 June 2023. doi:10.7326/M23-0669In this article, 2 discussants provide their answers to the following questions:1. Is computed tomography scanning necessary for the diagnosis of acute diverticulitis?2. Should antibiotics generally be used for treatment of this condition?3. Under what circumstances should a patient with acute diverticulitis be referred for colonoscopy or elective surgery?Key points for hospitalists include:Studies have shown that diagnosing acute diverticulitis using clinical symptoms alone can lead to misdiagnosis in up to 60% of patients. Computed tomography scanning is also helpful in diagnosing complicated diverticulitis (12% of cases) and evaluating alternative causes of a patient's symptoms. The role of imaging in diagnosing patients with recurrent episodes is unclear and carries known risks for radiation exposure and increased costs but can help determine whether the same colonic segment is involved, which can help guide future decisions on elective surgery.Diverticulitis is now thought to be primarily an inflammatory (rather than infectious) disorder, and multiple studies show that antibiotics do not necessarily lead to improved health outcomes in uncomplicated diverticulitis. Patients with uncomplicated diverticulitis who are nonpregnant, immunocompetent, and without significant comorbidities can be managed safely without antibiotics.Studies show that the prevalence of colon cancer discovery by colonoscopy after uncomplicated diverticulitis is low and may not be different from that of the general population; however, rates are higher after a diagnosis of complicated diverticulitis. Colonoscopy should be considered in patients who have not had one recently, especially after complicated episodes.Elective surgery for recurrent diverticulitis has not been shown to decrease rates of future emergency surgery or death but may decrease recurrence rates and improve quality of life. Decisions on elective surgery require careful risk–benefit discussions on a case-by-case basis.The Latest Highlights From Journal ClubHow does aspirin compare with enoxaparin in the prevention of venous thromboembolism complications or all-cause death in patients with limb or pelvic fractures?In limb or pelvic fracture, aspirin was noninferior to enoxaparin for reducing all-cause deathAnn Intern Med. 2023;176:JC56. doi:10.7326/J23-0024This RCT (n = 12 424) of patients hospitalized with limb or pelvic fractures (surgically or nonsurgically managed) found that 81 mg of aspirin daily was noninferior to 30 mg of enoxaparin twice a day in preventing all-cause death, death by pulmonary embolism, any pulmonary embolism, and proximal deep venous thromboses. Aspirin was found to be inferior in preventing rates of total deep venous thromboses (2.5% vs. 1.7% [95% CI, 0.28% to 1.31%]).In patients with prediabetes, does supplementing oral vitamin D reduce progression to type 2 diabetes mellitus?In prediabetes, oral vitamin D reduces progression to new-onset diabetesAnn Intern Med. 2023;176:JC55. doi:10.7326/J23-0030This systematic review and meta-analysis of 3 RCTs (n = 4190) showed that in patients with prediabetes, vitamin D supplementation reduced the risk for progression to new-onset diabetes (relative risk reduction after 3 years of 13% [95% CI, 3% to 22%]).Do cannabinoids have beneficial effects in patients with chronic neuropathic pain?In patients with chronic neuropathic pain, cannabinoids improve sleep and reduce pain vs. placeboAnn Intern Med. 2023;176:JC57. doi:10.7326/J23-0026This systematic review and meta-analysis of 8 RCTs (n = 1051) evaluating patients with chronic neuropathic pain found that cannabinoids improved sleep quality and reduced pain scores but were associated with an increase in daytime somnolence, nausea, and dizziness.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David H. Wesorick, MDAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Disclosures:Author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Key Clinical Concepts for Diagnosis and Treatment of Alcohol-Associated Hepatitis for Hospitalists Elisa Pose , and Ramón Bataller Metrics June 2023Volume 176, Issue 6 ePublished: 20 June 2023 Issue Published: June 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...